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PETITION FOR CERTIFICATE OF REHABILITATION AND PARDON

Optional Use Form: L-408.1 [Rev. July 15, 2011]

Penal Code, §§ 4852.01 and 4852.06

ATTORNEY OR PARTY WITHOUT ATTORNEY (Name & Address): Telephone No.: Fax No. (Optional): E-Mail Address (Optional): ATTORNEY FOR (Name): Bar No:

FOR COURT USE ONLY

SUPERIOR COURT OF CALIFORNIA, COUNTY OF ORANGE CENTRAL JUSTICE CENTER 700 CIVIC CENTER DRIVE WEST POST OFFICE BOX 22024 SANTA ANA, CA 92702-2024

In the Matter of the Application of ________________________________________________________________

Type Petitioner’s full name – First Middle Last and Suffix, if applicable Date of Birth: CII Number: Criminal Case Number(s):

PETITION FOR CERTIFICATE OF REHABILITATION AND PARDON (Penal Code § 4852.01 et seq.)

CASE NUMBER: M -

To the Superior Court of California, County of Orange: The above-named petitioner represents and shows that:

CONVICTION HISTORY

[All qualifying convictions must be listed. If you have more than three (3) qualifying convictions, attach additional sheets following the same format.]

Most Recent Qualifying Conviction

(A) Offense

On or about , petitioner was convicted of the crime of

Month Day, Year Indicate Crime and Code Section

on case number: in the County of , California.

(B) Type of Sentence or Disposition

Petitioner’s sentence for this offense was:

[Check the appropriate box]

Commitment to state prison or other state institution at ; Name of institution or city where located

Sentenced to state prison, but execution of sentence was suspended and petitioner was placed on probation.

Imposition of sentence was suspended and petitioner was placed on probation.

Name: Case Number: M-

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Penal Code, §§ 4852.01 and 4852.06

(C) Date of Release

Thereafter, on or about , petitioner was; Date released from custody

[Check the appropriate box(es)]

Discharged from state prison or other state institution after completing his/her sentence on (date)

.

Released on parole on (date)

.

Released from custody on probation (after serving a jail sentence as a condition of probation) on __________________(date

).

Released on probation (if no jail sentence was imposed) on __________________(date

).

(D) Pen. Code § 1203.4 History (For Probationers Only)

a) After termination of probation on ______________, a petition for relief under Penal Code section 1203.4

was granted on __________________(date).

b) Has petitioner been incarcerated in any prison, jail, detention facility, or other penal institution or agency

after his/her Penal Code section 1203.4 petition was granted? Yes_____ No_____

c) If yes, when and where? _______________________________.

d) Is petitioner currently on probation for the commission of any other felony? Yes_____ No_____

e) Petitioner presents the following evidence that he/she has resided in California for the past five years

(supporting documentation may be attached as exhibits to the petition): .

.

.

Second Most Recent Qualifying Conviction

(A) Offense





Petitioner’s sentence for this offense was: [Check the appropriate box]

Commitment to state prison or other state institution at ;

Name of institution or city where located




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Penal Code, §§ 4852.01 and 4852.06

(C) Date of Release




.


.


).


).






c) If yes, when and where? ______________________________




.

.

Third Most Recent Qualifying Conviction

(A) Offense





Petitioner’s sentence for this offense was: [Check the appropriate box]

Commitment to state prison or other state institution at ;

Name of institution or city where located




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Penal Code, §§ 4852.01 and 4852.06

(C) Date of Release




.


.


).


).






c) If yes, when and where? __________________




.

.

RESIDENCY HISTORY

I am now a resident of the State of California, and I have continuously resided in the State of California

from , to the present date.

I currently reside in the County of _______________________ at the following address:


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Penal Code, §§ 4852.01 and 4852.06

PETITIONER’S DECLARATION

During the period of my rehabilitation, I have lived an honest and upright life, conducted myself with sobriety and industry, and exhibited good moral character. I have conformed to and obeyed all the laws of the land. I request that the Court make its order declaring that I have been rehabilitated; and for a Certificate of Rehabilitation recommending that the Governor of the State of California grant me a full pardon. I declare under penalty of perjury under the laws of the State of California that the foregoing information is true and correct.

Date SIGNATURE OF PETITIONER TYPE OR PRINT NAME OF PETITIONER

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